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Secondary Lesions

The most common complication in open (as well as closed) head injury is brain edema. In gunshot wounds not resulting in immediate death, edema leads to an intracerebral space-occupying situation, which can cause herniation as well as brain stem hemorrhage.

The shot-induced opening of the skull and dura also allows atmospheric air to enter the cranium, giving rise to a mechanically induced pneumoencepha-los. Roentgenography can demonstrate the air in an epidural, subdural, subarachnoid, intraventricular or intracerebral location. In severe head injuries, especially if the missile penetrates the basal area, the large veins may be opened, leading to air embolism with consequent cardiorespiratory disturbances (air sinus wound - see Adams and Hirsch 1989). Embo-lized air may be detected in the right ventricle of the heart. The air can enter the body through the entrance or exit wound or, more often, through fracture systems involving the dural sinuses and the air spaces of the base of the skull. Fractures of the cranial base may lead to venous aspiration of necrotic brain tissue, resulting in a brain tissue embolism or in tracheal/bronchial aspiration of blood or, in rare cases, in brain tissue - each phenomenon indicative of a vital reaction.

Brain-tissue embolism of the lungs following gunshot wounding to the head, which is commonly associated with disruption of a major dural sinus, has been described by several authors (Ogilvy et al. 1988; Miyaishi et al. 1994; Levy et al. 1999). They concluded that a dramatic increase in intracranial pressure resulted in herniation of brain tissue into the simultaneously ruptured superior sagittal sinus, forcing brain tissue into the blood stream.

Every open brain injury bears the risk of bacterial contamination caused by primary or secondary bacterial infection (Sellier and Kneubuehl 2001) transported by the bullet into the tissue: a wound infection can lead to a suppurative meningitis, cerebral phlegmon or cerebral abscess. The prognosis of all of these forms of inflammation is extremely poor. As mentioned, even years after healing and scarring of an open brain injury a flare-up of infection can occur in an encapsulated focus, or a so-called delayed abscess may develop (see above).

An open communication between the CSF-con-taining spaces and the paranasal sinus may result in a cerebrospinal fluid rhinorrhea. Finally, mechanical sinusoidal injury may result in the formation of a bullet embolus within the vascular system. Move-

Fig. 8.19a-d. Imaging of secondary changes in isolated formalin-fixed brains. Photo documentation (a, c) versus MRI (b, d). a, b The missile track with surrounding bleeding as well as bleeding in the cerebral cortex (arrowheads, a, b) and in the ventricular system. Variations in the degree of translucence in cortical areas, the translucence being especially pronounced in the grooves between the gyri, possibly indicating hypoxic damage. c, d Axial T2-weighted MRI image of the incised missile track through the left basal ganglia, with a zone of hyperintense signal (arrows, d) possibly indicating tissue destruction secondary to the temporary cavitation (cf. Oehmichen et al. 2003)

Fig. 8.19a-d. Imaging of secondary changes in isolated formalin-fixed brains. Photo documentation (a, c) versus MRI (b, d). a, b The missile track with surrounding bleeding as well as bleeding in the cerebral cortex (arrowheads, a, b) and in the ventricular system. Variations in the degree of translucence in cortical areas, the translucence being especially pronounced in the grooves

Fig. 8.20a-d. In situ demonstration of human brain injured by gunshot to the head by postmortem CCT. a-d Entry of air into the skull and collapse of the missile track

ment or wandering of the missile may occur in some cases, especially along the spinal cord cavity.

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